Lesson 11: Neurogenic Bladder

Question 1

Pathology/Etiology - CNS Lesions

Answer 1

• CVA, Parkinson’s, TBI
• Reduced awareness of bladder filling intact
• Compromised ability to delay voiding until socially appropriate

Question 2

Pathology/Etiology - Suprasacral Cord Lesion

Answer 2

• Upper motor neuron lesions (S1-S2)
• Spinal cord injury, spina bifida, MS
• No communication between bladder/sphincter and cortex/brainstem
• No sensory awareness of bladder filling or control of voiding
• Bladder filling triggers reflex arc between cord and bladder
  — Forces detrusor contraction
• Sphincter may/may not open to permit unobstructed voiding

Question 3

Pathology/Etiology - Sacral Cord Lesion

Answer 3

• Lower motor neuron lesion
• Spinal cord injury, spina bifida, MS, lesion S2 - S4
• Loss of communication between bladder/sphincter and cortex/brainstem
• Loss of sensory awareness + volitional control
• Loss of reflex causes loss of detrusor contractility
  — Acontractible bladder
  — Severe retention
  — Overflow leakage

Question 4

Presentation - CNS Lesion

Answer 4

• frequency
• urgency
• nocturia
• urge incontinence

Question 5

Presentation - Suprasacral Lesion

Answer 5

• Diminished/absent awareness of bladder filling
• Limited/no control of voiding
• Bladder empties at unpredictable intervals
• Variable severity of bladder sphincter dyssynergia

Question 6

Presentation - Sacral Cord Lesion

Answer 6

• Diminished/absent awareness of bladder filling
• Limited/no control of voiding
• Severe distension with overflow leakage

Question 7

Diagnostics

Answer 7

Presumptive
- Neurological lesion/disorder
- Reduced/absent awareness of bladder filling
New onset MS
- Falls
- Blurred vision
- Bladder dysfunction
Wheelchair or scooter-bound
History + physical
- Absent anal wink
- BCR reflex absent
PVR
Videourodynamic studies

Question 8

Management - CNS Lesions

Answer 8

• Fluid management
• Constipation elimination
• PRN measures to improve ability to reach toilet
• Urge control strategies (Freeze-Squeeze-Breathe)
• Bladder retaining
• containment products + skin care

Rx
- Estrogen
- Antimuscarinics

Question 9

Management - Spinal Cord Lesions

Answer 9

Goals
- Prevent renal damage
- Promote effective bladder emptying
- Prevent/manage urinary incontinence

Behavioral therapies
- Clean intermittent catheterization
- Condom catheters for men

Pharmacologic
- Antimuscarinics, Beta-3 agonists
— Eliminate detrusor contractions
— Reduces risk of leakage between catheterizations
- Alpha-adrenergic antagonists
— Reduces/eliminated urethral resistance

Containment + absorbent products PRN

Question 10

Management - Surgical

Answer 10

Augmentation cystoplasty
- Improves bladder capacity
- Reduces detrusor pressures + contractility
- Indicated for outlet obstruction or dyssynergia
- Will need to clean intermittent catheterize for emptying

Urinary diversion
- Ileal conduit or continent diversion
- Best long-term option